CMS Issues Clarification on Home Health Face-to-Face and Medicare Eligibility
The Centers for Medicare and Medicaid Services (CMS) have posted a revised issue of Medlearn Matters (MLN), number SE1524, which is a special edition for Home Health Agencies (HHAs) who are submitting claims to Medicare Administrative Contractors (MACs).
SE1524 provides further clarification to MACs on conducting medical review and reporting under the Home Health Probe & Educate medical review strategy. These reviews relate to claims submitted by HHAs related to Medicare home health services and patient eligibility (certification/re-certification), as outlined in last year’s Calendar Year (CY) 2015 Home Health Prospective Payment System (HH PPS) Final Rule. Last year’s final rule eliminated the requirement of a face-to-face encounter narrative as part of the certification of patient eligibility for home health services. Many HHAs have been awaiting guidance on how to proceed regarding this change.
As outlined in SE1524, CMS is implementing a Probe and Educate medical review strategy to assess and promote provider understanding and compliance with the Medicare home health eligibility requirements. CMS is issuing guidance to MACs about how to select home health claims for review during the “Probe and Educate” program for home health episodes that began on or after Aug.1, 2015.
CMS anticipates MACs will begin sending Additional Documentation Requests (ADRs) after Oct. 1, 2015, and the first round of claim reviews and provider education will conclude in approximately one year.
CMS will direct Home Heath MACs to select a sample of five claims for pre-payment review from each HHA within their jurisdiction. Based on the results of these initial reviews, MACs will conduct provider specific educational outreach. MACs will be denying each non-compliant claim and will outline the reasons for denial in a letter to the HHA. CMS will be instructing MACs to offer individualized telephone calls/education to all HHAs with errors in their claim sample. Included in SE1524 is a table outlining MAC actions following HHA probe reviews with findings ranging from zero/minor concerns to moderate/major concerns.
Contact: Cheryl Udell, cudell@leadingageny.org, 518-867-8871